Quality indicators: they’re all important, but the picture isn’t complete

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What do we mean when we talk about quality in health and social care? The QualityWatch website tracks over 300 different indicators of quality of care, categorising and grouping them in a variety of ways in order to provide a better understanding of how the health service is performing.

As an independent voice holding up a mirror to healthcare quality, we thought it would be important to check how the available data and indicators selected matched with views on the importance of different aspects of quality among three distinct groups: patients and service users; healthcare professionals; and policy-makers. Would they agree that we’re tracking data on the important aspects of health care? If some key elements are missing, where else should we be looking? Consensus on quality provides some answers to these questions.

A genuine consensus

We expected that there would be some divergence of views between the groups and that this might be quite marked in relation to some issues. It therefore came as quite a surprise when the analysis of questionnaire responses and focus group discussions was carried out: ratings were consistent across the board, translating into page after page of similar-looking graphs. All of which showed that our respondents agreed that the current QualityWatch indicators do reflect the important aspects of quality of care, with the majority of statements rated as ‘important’ or ‘very important’.

Our researchers were initially somewhat disappointed as this gave little scope to carry out sophisticated analysis to explore variations in responses. However, it was also reassuring: the results validated the original choice of indicators for the programme selected by the experts on quality of care and the concerns of our data analysts to ensure we selected the more robust of the available indicators.

Overall, patients and carers, healthcare professionals and policy-makers were consistent in ranking the themes under ‘safety’ as the most important aspects of quality of care, followed by ‘effectiveness’. Within this there were differences, though – patients were more pragmatic in many cases, accepting the limitations that services are not able to meet the highest standards across all quality dimensions, all the time, particularly where there are resource constraints.

Using findings effectively

So, how best to use this information? We certainly won’t just be sitting back and monitoring the existing indicators. It was clear from the free-text comments and discussion in focus groups that the available data misses some important – and more nuanced – aspects of quality. For example, when asked about equity of access to care, respondents were concerned about care being appropriate for the individual, as much as the same level of care and services being available to all.

It was noticeable that some indicators linking to key policy areas, such as ‘GP surgeries offer a wide range of services’ and ‘Places where care is provided are recommended by patients’ were among the statements marked as less important. Patients and service users were very conscious of the subjective nature of individual recommendations, indicating that they would want to consider recommendations alongside other sources of data.

Equally, it’s clear to everyone looking at the indicators that the spread of available data is hugely skewed towards hospital services. It was pointed out that the lack of indicators for community and social care leaves a large gap in assessments of care quality. Because of the ways in which data sets have been developed and the drivers to prioritise clinical data, the quality indicators are not evenly spread across the domains of quality; there are overwhelmingly more indicators on clinical effectiveness and safety than there are for patient-centredness, or for equity of care.

Patients and service users highlighted the need for indicators on quality of care transfers, with comments from focus groups showing it as a grave concern based on experiences of very poor practice. In addition, it was suggested that that use of resources is a key quality issue in the healthcare system that is not being appropriately reported. Indicators of efficiency and effective use of resources were a vital area to be developed and reported on more consistently.

Completing the picture

This consensus exercise has shown that the indicators we have are considered relevant. They provide a way to monitor some aspects of quality of care, but a lot more needs to be done to develop the data so that, overall, we have access to a more complete picture of quality that helps us to understand where high quality is being achieved, where quality needs to be improved and how quality of care is changing over time.